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As of October 31, 2018, the CDC has reported 457 clinical cases of confirmed C auris infection with a majority in New York (>50%), New Jersey, and Illinois.

Update on Candida auris: Statistics, Detection, and a Phase 2 Trial

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

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Nigel McCracken, PhD, presents a diagnostic test to identify early T cell dysfunction in post-acute infection syndromes like Long COVID and ME/CFS, aiming to improve treatment strategies before symptoms escalate.

Detecting T Cell Dysfunction in Post-Acute Infection Syndromes

At IDWeek, Nigel McCracken, PhD, COO of Virax Biolabs, discussed their work on developing a diagnostic test for early detection of T cell dysfunction in post-acute infection syndromes like Long COVID, chronic fatigue syndrome, and Lyme disease. The test aims to identify T-cell exhaustion by measuring cell surface markers and cytokines released by B and T-cells. Early detection could enable better treatment management, including lifestyle changes and antioxidants, before symptoms become irreversible. The test could also differentiate between symptoms caused by post-acute infections and those requiring specific treatments for conditions like depression and anxiety.

Focusing on the implications of viral infections such as SARS-CoV and RSV, he explained, “We’re speaking to investigators and clinicians around post-acute infection syndromes. We’ve obviously heard about SARS-CoV-2 and RSV. The viral infections themselves actually do cause problems afterwards. And we know, and we’ve heard about Long COVID, we know things about chronic fatigue syndrome, or even post-acute Lyme disease. The symptoms, if you leave them long enough, are all the same.”

McCracken emphasized the importance of developing diagnostics to identify early signs of T-cell dysfunction, which he believes plays a significant role in the symptoms associated with these syndromes. “What we’re trying to do is basically try and develop a diagnostic to identify the early signs of T cell dysfunction, because we believe that the dysfunctional immune system plays quite a big role in a lot of the main symptoms associated with post-acute infection syndromes like Lyme disease as well as Long COVID,” he noted.

He explained the two types of immune responses: innate and adaptive. “There’s an innate immune response, which is a quick response, and then there’s an adaptive response. The adaptive response is more focused, involving B cells that form antibodies and T cells that are cytotoxic, meant to kill the virus and remove it from the body.”

McCracken explained that their test aims to identify T cell dysfunction early, before it becomes irreversible. “We hope to be able to identify that early to allow treatment management. There are no drugs specifically at this moment, but drug companies are working on Long COVID treatments. Meanwhile, we can focus on lifestyle changes or dietary adjustments, such as antioxidants, to reduce chronic inflammation.”

He described the lengthy journey many Long COVID patients experience. “The journey of a Long COVID patient is long. It can be up to 18 months. You’re going to get tested for many things. Most of the diagnosis is self-diagnosed. I think anyone who can understand what’s causing the problem can help address it.”

McCracken noted that chronic inflammation plays a role in the response to viral infections. “You need chronic inflammation to create an environment to get rid of a virus, but you don’t want it to last for a long period. There are things we can do to reduce chronic inflammation, like lifestyle changes and antioxidants.”

Reflecting on the broader implications of these conditions, Nigel expressed hope that the increased awareness surrounding Long COVID could benefit others suffering from chronic conditions. “I think the whole thing around Long COVID has helped patients who have dealt with chronic fatigue syndrome for years. It has brought attention to a general problem around chronic inflammatory conditions. We really need to do something about it, as it is causing a huge healthcare problem and a significant burden on society.”

Watch our latest roundtable series to learn more about Long COVID: 

A Deep Dive: Understanding the Neurological Toll of Long COVID

Nigel McCracken, PhD, presents a diagnostic test to identify early T cell dysfunction in syndromes like Long COVID and ME/CFS, aiming to improve treatment strategies before symptoms escalate.

Conferences

Corey Fishman and Steven Aronin, MD discussed trial highlights of Orlynvah for uncomplicated urinary tract infections, while also outlining plans to seek partners for market launch to address antibiotic resistance and enhance treatment options for patients.

SURE1 and REASSURE Trials Pave Way for FDA Approval of Orlynvah

This discussion with Corey Fishman, CEO of Iterum Therapeutics, and Steven Aronin, MD, SVP of Clinical Development at Iterum, elaborated on the approval of Orlynvah for uncomplicated urinary tract infections (uUTIs). Their insights focused on the SURE1 and REASSURE trials, which compared Orlynvah to ciprofloxacin and augmentin, respectively, paving the way for its FDA approval.

The SURE1 trial demonstrated that Orlynvah was superior to ciprofloxacin in patients with infections caused by ciprofloxacin-resistant organisms. Although, the trial also revealed an unexpected outcome: Orlynvah did not show non-inferiority against ciprofloxacin in patients with susceptible organisms. Aronin noted, "What was unexpected was the other population, the population of patients who had a ciprofloxacin-susceptible organism. We did not show non-inferiority, and that was unexpected.”

The researchers attribute this anomaly to the differential impact of antibiotics on the bacterial flora in patients. “Cipro sticks around a long time,” explained Aronin. “Because it sticks around a lot longer than beta-lactam antibiotics like sulopenem, it has a longer effect on the bacteria that are not causing infection but are just sitting there.” This prolonged presence led to better outcomes in the 12-day follow-up, making ciprofloxacin appear more effective in some cases.

Elaborating on cipro, Fishman said, “The safety profile is a major concern, and it is no longer recommended as a first-line agent. There is a significant resistance issue with Cipro, primarily due to safety challenges. There are several severe issues that can arise, and for uncomplicated infections, both the FDA and EMA have stated that it no longer makes sense to use Cipro as a first-line treatment for uncomplicated infections like uUTIs.”

Recognizing the need for further evidence to prove Orlynvah safe and efficacious, the FDA required they conduct a second study. TheTo address the unexpected findings from the SURE1 trial, they set up the REASSURE trial compared Orlynvah to augmentin, confirmed Orlynvah's superiority in susceptible populations and established non-inferiority across the overall population. Fishman emphasized the importance of this approval for empiric therapy in community settings, particularly where options are limited.

“The overall population is crucial,” Aronin noted. “Patients who show up with symptoms of a UTI and have an abnormal urinalysis—they have a UTI, but you don't know the bugs yet. That's the treating doctor’s population. It's important for the treating doctor to understand that we're just as good as the other agents in this space.”

Fishman added, “This is a very different model than historical antibiotics. Most that have launched recently have a big component in the hospital, but in the community, primary care doctors are the main prescribers. This is where sulopen can be incredibly valuable for appropriate patients.”

Looking ahead, Iterum Therapeutics plans to seek a strategic partner for the launch of Orlynvah. Fishman stated, “Now that we have approval, we will renew those efforts to find a partner to work with us in some capacity. It’s not just about being an antibiotic company; it’s about who the physicians are that are currently in your call pattern.”

The team is optimistic about finding a partner who can effectively introduce Orlynvah to the market, targeting companies with products that are already prescribed by primary care physicians and specialists like urologists and OB-GYNs. “We’d love to do that sooner rather than later because we want to get this product on the market, treating patients and helping physicians with limited options,” Fishman concluded.

As excitement builds, Aronin remarked, “I just came back from the Infectious Disease Annual Conference in Los Angeles, and lots of doctors came up to me. They’re very excited about the prospect of this being available to treat their patients. Everybody's talking about stewardship, but they also understand there's an unmet need here.”

The approval of Orlynvah not only fills a critical gap in UTI treatment options but also represents a significant advancement in addressing antibiotic resistance, ultimately benefiting both physicians and patients. 

FDA Approves Oral Sulopenem (Orlynvah) for Uncomplicated Urinary Tract Infections

Corey Fishman and Steven Aronin, MD, discussed trial highlights of Orlynvah for uncomplicated urinary tract infections and outlining plans to seek partners for a market launch to address antibiotic resistance and enhance patient treatment options.

SURE1 and REASSURE Trials Paved Way for FDA Approval of Orlynvah

In the second part of their interview, Debika Bhattacharya, MD MSc, and Su H. Wang, MD, MPH, FACP, continue the conversation around the difficulties of getting people into care

The Challenges of Hepatitis B Clinical Care Within Underserved Communities

Individuals who contract hepatitis B are often living on the margins and may not be in a position to get the proper medical care needed. Fortunately, both new US federal and global guidelines are looking to address hepatitis B and get more people into the continuum of care. The overarching public health goals with the new hepatitis B guidelines are to make significant changes to HBV testing and clinical care including increasing vaccinations, extending universal screening to everyone at least once during a lifetime for all adults 18 years of age and older, reducing the number of new infections, and getting those patients who have contracted the disease the therapy to address their infections.

Debika Bhattacharya, MD MSc, clinical professor, David Geffen School of Medicine, University of California, Los Angeles (UCLA), believes the new universal hepatitis B screening guidelines is going to be a difference maker. “The universal screening guidelines that have been developed for hepatitis B are really going to help communities that don't necessarily see physicians or have access to health care, even in the United States on a regular basis, because with the previous guidelines, you were asking risk-based questions and trying to risk stratify persons as to whether or not they needed Hepatitis B screening. Now we're doing screening for everybody, so that allows us to serve more and to screen more.”

“We're really hopeful that primary care providers can now take on hepatitis B care with the simpler guidelines,” said Su H. Wang, MD, MPH, FACP, medical director, Viral Hepatitis Programs & the Center for Asian Health at the Cooperman Barnabas Medical Center, RWJBarnabas Health. “So in lower resource countries, people are not going to easily able to easily find a hepatologist, or a GI doctor, or infectious disease doctor. And so we want to be able to empower frontline clinicians to be able to take on hepatitis B care.”

’s conversation with Bhattacharya and Wang discuss the new measures as well as the role of interdisciplinary collaboration in developing the guidelines.

To watch the first installment about hepatitis B guidelines, check out their interview 

In the second part of their interview, Debika Bhattacharya, MD MSc, and Su H. Wang, MD, MPH, FACP, continue the conversation around the difficulties of getting people into care, and what the new hepatitis B guidelines hope to improve in this area.

, commonly known as bird flu, has had an increase in human cases in the United States recently, particularly among poultry and dairy workers. H5N1 has primarily circulated in the Midwest, with these cases raising concerns about potential human transmission and broader public health implications. Understanding the current landscape of H5N1, including recent data and prevention strategies, is essential as health officials monitor the situation.

The CDC is monitoring influenza data at national, state, and local levels. As of October 9, 2024, 18 human cases of H5N1 have been reported in the US since 2022. Since February 2022, more than 15,500 individuals have been monitored after exposure to infected animals, with 590 tested for novel influenza A. Recently, approximately 6100 individuals have been monitored, including 3350 exposed to dairy cows and 2800 to birds and other animals.

Currently, CDC surveillance systems indicate no unusual flu activity related to H5N1. In the week ending October 19, 2024, public health laboratories reported no positive tests for novel influenza A, and wastewater monitoring detected H5 at only 1 out of 320 sites.

CDC continues to collaborate with the USDA, FDA, and state health officials using the One Health approach to monitor the situation. The agency has deployed a multilingual epidemiological field team to assist local health departments with outreach and surveillance efforts. To date, more than 5100 individuals exposed to potentially infected animals have been monitored, and more than 54,000 specimens have been tested for H5N1viruses.

 marked the 14th reported case this year and was the first without documented occupational exposure. Identified through seasonal flu surveillance, the patient was hospitalized but has since recovered. Experts suggest that transmission routes may include incidental contact with infected animals, indicating a need for further research into risk factors.

Meghan Davis, DVM, PhD, MPH, an associate professor at Johns Hopkins Bloomberg School of Public Health, discussed potential alternative transmission routes for avian influenza, highlighting the Missouri case as an example of variable exposure routes beyond direct animal contact. “What the case in Missouri really highlights is that the transmission routes are quite variable. It's not just occupational contact with live animals; it could also be from incidental contact with animals, and we don't yet fully recognize what those risk factors might be for people,” she said.

The serological testing methods used in the CDC's investigation of the Missouri H5N1 case included several assays. The primary method was the Microneutralization (MN) assay, which identifies influenza virus-specific antibodies in blood sera by measuring the ability of these antibodies to neutralize the virus. The Hemagglutinin Inhibition (HI) assay was employed to detect antibodies to the hemagglutinin of specific influenza viruses; this test assesses the ability of antibodies to agglutinate red blood cells, using multiple types of red blood cells for detection.

Another method used was the Multiplex Antibody Detection Assay (MIADA), which looks for antibody binding to multiple influenza antigen targets (28-plex) and measures total immunoglobulin responses, including IgG, IgM, and IgA. A Seasonal Influenza Serum Absorption step was included to remove antibodies against seasonal influenza viruses to reduce cross-reactivity, enhancing the specificity of the H5N1 testing.

The CDC also developed 2 Reverse Genetics (RG) viruses that mirrored the antigenic changes found in the H5N1 virus from the Missouri case. This allowed for precise serological testing. Together, these methods provided a comprehensive assessment of immune responses and potential previous exposure or infection with H5N1 in the individuals tested.

, the Department of Public Health confirmed 7 probable cases of H5N1 linked to dairy farm outbreaks. Most infections have occurred among farm workers, with mild symptoms reported.

To continue, the CDC confirmed H5 infections in two of four poultry cullers from 

 state, marking the state's first cases. Despite the confirmed cases, public health officials maintain that the risk to the public remains low, although those with occupational exposure to sick animals face a higher risk.

Despite the rise in cases, Davis said, “The good news, however, is that despite the human cases linked to poultry outbreaks and dairy cow infections primarily affecting workers, no human-to-human transmission has been identified yet. This is an important aspect to monitor closely.”

One Health: An Approach Bridging Human, Animal, and Environmental Health

The One Health approach is a collaborative framework that recognizes the interconnectedness of human, animal, and environmental health. It advocates for a multidisciplinary strategy to address health challenges, particularly zoonotic diseases, by integrating expertise from fields like medicine, veterinary science, and environmental science to promote holistic solutions and sustainable ecosystems.

Davis is a proponent of the One Health approach. She said, “One Health is foundational to many infectious diseases that are zoonotic. What is recognized with highly pathogenic avian influenza is that it has been present for a considerable period. Like seasonal influenza in humans, there are influenza strains that predominantly affect birds. These include reservoirs—types of birds that carry the virus but don't get very sick themselves—such as waterfowl like ducks. On the other hand, there are birds that can become severely ill and die, including domestic poultry like broiler chickens, layer chickens (for meat and eggs), turkeys, and other species kept by humans.”

According to the CDC spokesperson, “CDC’s One Health approach recognizes the interconnection between people, animals, plants, and their shared environment, which is highly relevant in our surveillance and response strategies for H5N1.”

Current Status of Human Vaccine Developments for H5N1

According to the CDC’s October 11, 2024, update, the CDC has allocated more than 100,000 doses of seasonal flu vaccine for farm workers in 12 states with positive H5 cases to mitigate the risk of spread. Although the vaccine does not protect against H5N1, the CDC noted that it can reduce severe illness from seasonal flu as well as aid in the identification of potential H5N1 cases.

Additionally, the CDC is testing existing candidate vaccines for effectiveness against current H5N1 strains. Recent studies suggest that licensed adjuvanted H5N1 vaccines may generate cross-neutralizing antibodies against circulating variants, aiding in pandemic preparedness.

They are also genetic sequencing of the H5N1 viruses from infected individuals has shown no significant mutations associated with increased infectivity or reduced susceptibility to available antiviral treatments. This is important for understanding the current vaccine landscape, as it suggests that the current vaccines may still be relevant.

 in July 2024 found the stockpiled adjuvanted H5N1 vaccines demonstrate potential effectiveness against H5N1 clade 2.3.4.4b, highlighting their importance in pandemic preparedness efforts. The study assessed the binding, hemagglutination inhibition, and neutralizing antibody responses in adults vaccinated with three licensed H5N1 vaccines derived from earlier strains (A/Vietnam, clade 1; A/Indonesia, clade 2.1) with and without adjuvants.

Vaccination with the 2 adjuvanted H5N1 vaccines resulted in cross-reactive binding and cross-neutralizing antibodies against the HPAI clade 2.3.4.4b A/Astrakhan/3212/2020 virus. Seroconversion rates ranged from 60% to 95% after 2 doses of the AS03-adjuvanted A/Indonesia vaccine or 3 doses of the MF59-adjuvanted A/Vietnam vaccine.

 is the primary antiviral, prescribed at 75 mg twice daily for 5 days for outpatients, and should be given promptly to hospitalized patients, regardless of illness onset. For immunocompromised patients, combination therapy may help prevent antiviral resistance. Treatment should not be delayed while awaiting lab results, and duration may be extended for severely ill patients based on clinical judgment.

Intravenous peramivir is an alternative for those who cannot take oral medications, recommended for at least 5 days. Higher doses of oseltamivir have not shown additional benefits, so healthcare providers should consult CDC resources for dosing guidance. Treatment with antivirals like oseltamivir is recommended for suspected H5N1 cases. Healthcare providers are advised to start treatment without delay, even before laboratory confirmation. Monitoring for antiviral resistance, especially in hospitalized patients, is important.

Safety Measures for Veterinary Professionals and Clients

As avian influenza continues to rise as a threat to animals and the safety of veterinary professionals, it is becoming crucial for teams to understand the disease and how to protect patients, clients, and themselves—especially since avian influenza has now been transmitted to different species, including humans.

 In Spring 2024, Texas reported the detection of the disease in dairy farms and in other animals such as dolphins.

The CDC advises that it is currently unlikely humans can become infected through an infected stray, wild, feral, or domestic cat, but human infection can be possible if there is prolonged unprotected exposure to infected animals in individuals not wearing personal protective equipment.

“If you have an animal that has a fever, is lethargic, maybe [they are] having some discharge from the eyes or nose, coughing, trouble, breathing, wheezing, and especially an elevated body temperature, any of those flu-like symptoms will be things that you'll want to be thinking about as potential symptoms of avian influenza,” Kemba Marshall, MPH, DVM, DABVP (Avian), SHRM-CP, founder of Marshall Recruiting Consortium, explained.

“Now, specifically, let’s turn our attention towards backyard poultry. Chickens can do the same things, they can still cough, wheeze, and have discharged from the eyes and nose. Their comb, the skin that you see on the top of their head, you may see that become discolored. Affected laying hens may have an abnormally shaped eggs, which may be kind of lumpy, bumpy, or what we just call like a misshapen egg,” she continued.

Veterinary professionals who suspect that they have a case of avian influenza based on clinical signs, will need to run a polymerase chain reaction (PCR) test. Veterinary teams should wear personal protection equipment (PPE) for all suspect avian influenza cases and while collecting diagnostic samples. For testing, veterinary teams are encouraged to reach out to their state veterinarian prior to sample collection because state labs, which are part of the National Veterinary Diagnostic Laboratory, are often the only labs permitted to perform avian influenza testing. State labs should be contacted before any post-mortem samples are collected to ensure proper sampling techniques. As a reminder, carcass can be refrigerated or chilled but should never be frozen prior to diagnostic sample collection.

Nasal and ocular swabs, urine, and whole blood samples can be submitted to the appropriate diagnostic laboratory. If the suspected animal is deceased, veterinary teams should also submit a 1” x 2” section of brain.

 All samples should be fresh, refrigerated, and shipped in an insulated box with ice packs.

Marshall explained that biosecurity is the key to managing the virus on farms and amongst animals. She encourages anyone coming into your house or farm to wear clean clothing, hats, and shoes to avoid cross contamination and disease spread via fomites. If animals must be transported, it is important to thoroughly disinfect all shipping, handling, and transport areas and vehicles, especially for larger animals on the road for shows or competitions.

“Biosecurity also means we should be able to have a record and a log of every person that came to the fair, animal exhibition, or farm. We want to keep a record of who was there, how long they were there, and if that person had been to other farms that day or that week. Farms should have designated entry points, wheel or vehicle wash stations, and separate holding areas or pens for incoming and outgoing animals. All state ordinances and laws should be followed regarding intra and interstate health certificates” Marshall continued.

“We cannot understate the importance of PPE…. which includes gloves, goggles, gowns, and face masks. In addition, hand hygiene is critical and includes very frequent and thorough hand washing with soap and water. Individuals should be mindful of not handling animals or animal matter and then immediately handling their cell phones. Individuals should not be on their cell phones texting or making notes or anything like that, and then turn around and scroll on that same cell phone when you're eating your ham sandwich or drinking your coffee,” Marshall noted.

As avian influenza has now been detected in felines, it is recommended to use caution when letting cats go outside, especially if they live within an agricultural setting. The CDC also recommends feline owners who have interacted with animals or birds with unknown health status change their clothes and shoes before interacting with personal pets.

 For owners of potentially infected pets, veterinarians should refer them to their state's Department of Public Health and Environment in order to monitor human exposure and potential human disease transmission.

For veterinarians, it is recommended to use isolation and appropriate patient handling protocols for suspected infectious and/or zoonotic disease cases, including negative airflow if possible. Staff should contain and thoroughly disinfect any equipment used to treat the potentially infected patient. Staff should wear proper PPE and limit staff contact with animals in isolation facilities to the best of their abilities.

Navigating the Risks: How H5N1 Might Cross into Human Populations

 contaminated with the droppings of infected animals may harbor the virus. Individuals who encounter contaminated water or who work in wastewater management could be at risk, especially if proper precautions are not taken.

Genetic testing in wastewater is increasingly used to track the spread of H5N1 in the US, particularly among dairy herds, raising public health concerns. While PCR testing is standard for virus detection, its specificity issues may miss some variants. Recent research found H5N1 in wastewater across nine Texas cities, suggesting animal rather than human sources. Individuals in close contact with infected animals or consuming unpasteurized milk face greater risk. Overall, wastewater testing is becoming essential for disease surveillance.

If poultry infected with avian influenza contaminates milk products, consuming unpasteurized or 

 could pose a risk of transmission. Pasteurization typically eliminates such viruses, but raw products carry a higher risk.

Health officials warn against consuming unpasteurized milk due to the H5N1 bird flu virus found in more than 140 US dairy herds and high levels in raw milk. The virus can remain infectious on milking equipment for several hours and in unpasteurized milk for at least 1 hour. The milking process, which involves automated equipment and manual cleaning, increases exposure risks for workers.

A Historical Perspective: Understanding Avian Influenza Through the Years

Avian flu can be traced back to northern Italy in 1878, when a contagious disease of poultry with a high mortality rate was described, and then referred to as “fowl plague.” It was eventually determined that the “fowl plague” described was caused by a virus, which in 1955 was determined to be a type A influenza virus. In 1971, influenza viruses were originally classified based on the antigenic properties of their structural and surface proteins nucleoprotein hemagglutinin and neuraminidase proteins, as well as the species of origin. In 1981, the name “fowl plague” was officially replaced with avian influenza at the First International Symposium of Avian Influenza.

According to Justin Brown, DVM, PhD, wildlife veterinarian and assistant teaching professor at Penn State University, the avian influenza virus has historically been most commonly detected within wild birds—mostly waterfowl, shorebirds, and gulls. However, this unique strain of the virus, H5N1 highly pathogenic avian influenza virus, has very unique properties that are very different from most avian influenza viruses, including the ability to infect and cause disease in a wide diversity of avian and mammal hosts.

“A wide diversity of avian influenza viruses circulate in wild birds without causing any outward signs of disease.Historically, when those have been low pathogenic and caused mild or no disease if they transmitted to chickens.However, if those low pathogenic avian influenza viruses were of the H5 or H7 subtype and spilled over into chickens, they could adapt to chickens and mutate to become highly pathogenic viruses that were associated with acute and high mortality.This historically has been a rare event.Once the virus adapts to chickens or related poultry species, these highly pathogenic avian influenza viruses have rarely transmitted back to wild birds.”

“This one-way spillover of avian influenza virus from a wild bird reservoir to poultry no longer explains what we are seeing with the H5N1 strains that are impacting the health of wild birds, poultry, and an increasing number of mammal species in multiple continents.This group of highly pathogenic avian influenza viruses was first isolated in China in 1997. Since then, these viruses have evolved into a group of viruses that differ genetically and biologically.Specifically, these H5N1 viruses have exhibited a unique ability to infect and cause disease in a wide range of bird and mammal hosts. As opposed to the historic “one-way” spillover events, some strains of this virus have re-adapted back to wild birds.What this means is that certain wild bird species can serve as reservoirs for the virus; this is very rare for a highly pathogenic avian influenza virus and makes control or eradication of the virus extremely difficult.

Brown also explained there are multiple routes for the virus to spread from wild birds, including direct contact with an infected bird (dead or alive) or contact with an infected birds feces (a common route that the virus is shed).Exposure to the virus through infected environmental samples has occurred and is possible.This often may be in habitats in which large numbers of infected birds are present and can contaminate the environment with virus, such as waterfowl habitat.

As the threat of infectious diseases continues to grow, veterinarians and animal health experts are facing an increasing challenge in managing species that may serve as reservoirs for transmission. Although the traditional focus for control of avian influenza has been on species like waterfowl and gulls, the list of potential infected bird or mammal species is expanding. This list includes wild and domestic felines. Brown stated that ensuring separation between naive host species and known reservoirs remains a key strategy.

Veterinary and public health officials share the important roles of surveillance and prevention strategies, insights on the virus's transmission pathways, historical context, the One Health approach, and highlights effective precautionary measures to mitigate H5N1 risks.

Thy N. Le, PharmD, BCPS-AQ-ID

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